Survivor Scholarship Application

Yes

No

Yes

No

$1,500 – CIBC Survivor Scholarship

$5,000 – S.T.E.M

First

Last

Enter Email

Confirm Email

Street Address

Address Line 2

City

Province
AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon
Postal Code

First

Last

Yes

No

BC Children’s Hospital – Vancouver, British Columbia

Alberta Children’s Hospital – Calgary, Alberta

Stollery Children’s Hospital – Edmonton, Alberta

Jim Pattison Children’s Hospital – Saskatoon, Saskatchewan

Winnipeg Children’s Hospital – Winnipeg, Manitoba

Children’s Hospital at London Health Sciences Centre – London, Ontario

McMaster Children’s Hospital – Hamilton, Ontario

Children’s Hospital of Eastern Ontario (CHEO) – Ottawa, Ontario

The Hospital for Sick Children (SickKids) – Toronto, Ontario

The Montreal Children’s Hospital – Montreal, Quebec

CHU Sainte-Justine – Montreal, Quebec

IWK Health Centre – Halifax, Nova Scotia

Janeway Children’s Health and Rehabilitation Centre – St. John’s, Newfoundland and Labrador

Other

First

Last

Please list high school details. School NameCityProvinceCountryGraduation Year  Add Remove

Yes

No

Please list the Post Secondary School you are attending or plan to attend.School NameCityProvinceCountry  Add Remove

This form is designed for collection of personal information to asses the eligibility of an individual for the Childhood Cancer Canada Survivor Scholarship Program. Personal information including medical details and government id is required. By continuing you agree to allowing Childhood Cancer Canada to capture, store and use this information for the sole purpose of administering the Scholarship Program. I agree to the terms and conditions.